A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?
Recommend the AP come back later when the record is available
Log out so the AP can log in to document the vital signs
Offer to chart the vital signs for the AP
Allow the AP to document the vital signs prior to logging out
The Correct Answer is B
a. Recommend the AP come back later when the record is available:
This option delays the documentation process unnecessarily and may inconvenience the AP.
It doesn't address the issue of maintaining patient confidentiality and accurate documentation.
b. Log out so the AP can log in to document the vital signs:
This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.
It maintains patient confidentiality and adheres to HIPAA regulations.
It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.
c. Offer to chart the vital signs for the AP:
This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.
It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.
d. Allow the AP to document the vital signs prior to logging out:
Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.
It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. A client who is 37 weeks gestation and has an L/S ratio of 2:1:
An L/S (Lecithin/Sphingomyelin) ratio of 2:1 indicates mature fetal lungs, which is a positive indicator. While this client may be nearing term, the presence of mature fetal lungs does not necessarily warrant an interdisciplinary care conference unless there are other complications or high-risk factors present.
b. A client who is 28 weeks gestation and has a negative Coombs's titer:
A negative Coombs's titer suggests that the client does not have antibodies against Rh-positive blood cells, which is a normal finding. At 28 weeks gestation, this client may not require an interdisciplinary care conference unless there are other significant complications or risk factors present.
c. A client who is at 39 weeks gestation and has a negative contraction stress test:
A negative contraction stress test indicates that the fetus is not experiencing distress during uterine contractions, which is a reassuring finding. At 39 weeks gestation, while this client may be nearing term, a negative contraction stress test alone may not warrant an interdisciplinary care conference unless there are other concerning factors present.
d. A client who is at 35 weeks gestation and has a biophysical profile of 6:
A biophysical profile (BPP) of 6 is on the lower end of the scale and may indicate potential fetal compromise or risk. This client may benefit from further evaluation and possibly closer monitoring, which could warrant an interdisciplinary care conference to discuss management and potential interventions.
Correct Answer is C
Explanation
a. Providing a 10-minute rest period prior to meals:
This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime:
The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.
c. Instructing the client to place her chin toward her chest when swallowing:
This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.
d. Withholding fluids until the end of the meal:
Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.
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